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Insurance Covered my Reconstructive Plastic Surgery

PublishedDecember 7, 2012

Alright, I know this is the topic that everyone has been waiting for me to discuss. How I got my insurance to cover my plastic surgeries.

Let me first say that I have largely waited to talk about this very publicly until after the surgeries were done and after the bills were all paid. But I’m pretty comfortable at this point so I’m willing to discuss it a bit more. Let me say as an early Disclaimer; I was told every step of the way that my insurance would NOT cover these surgeries. I have been told by every professional involved that this was an unprecedented occurrence.

I also, knew very early on that having these skin removal surgeries was going to be a necessity for me for several reasons. The excess skin caused me pain and rashes that made exercise very difficult and that was problematic both for my weight loss, weight maintenance and my future career as a personal trainer. I knew from the beginning that if my insurance did NOT cover these surgeries I was going to have to figure out a way to pay for them.

So let’s talk first about what I was told by my insurance company and doctors going into this. I was informed by my insurance company that there was no coverage for elective plastic surgery and anything that was not “Medically Necessary” was considered elective. I was informed by both my Bariatric Surgeon and my Primary Care Doctor that I would have issues with excess skin. I was informed from as early out as the Orientation Seminar I had to attend that the only Reconstructive Plastic Surgery they were seeing the insurance companies approve was the panniculetomy; The surgery that removes the rather large part of the “stomach” that hangs down over the abdomen called the panniculus.

Prior to selecting a surgeon I consulted with two different plastic surgeons that I had heard speak at orientation seminars. Both plastic surgeons provided me with the same basic information. I’d be looking at anywhere between 3-5 different surgeries and my insurance would only be expected to cover the panniculetomy portion of the surgery.

Now the first big decision that I was faced with was what surgeon I was going to go with. I’m going to be perfectly honest, and though I won’t name the surgeon that I did not use, my reason for deciding not to go with that surgeon had to do with the fact that his surgery coordinator when I tried to discuss with her how I felt my insurance needed to be approached in regard to billing and about extenuating circumstances that I felt could very well lead us to getting the insurance to approve more than what anyone else expected, her response to me was “We don’t do it that way.” After speaking with the woman personally later and telling her why I chose a different surgeon she apologized for her words and informed me that I misunderstood her and that she would have done anything necessary to get the insurance approval. Her words didn’t imply that however, and they sent me searching for a surgeon that was going to work with me on working with my insurance. This after all was going to mean the difference of like .. lets just say A LOT of money. Could you blame me?

I decided I was going to consult with a different Surgeon so I contacted one of the other bariatric surgery centers of excellence in the area and asked them who they referred their patients too. That’s how I ended up meeting Dr. Shannon O’Brien at the Waldorf Center. I selected Dr. O’Brien as my surgeon for two major reasons; she was willing to do more work in less surgeries, which overall meant less time and money for me and she was willing to listen to me about the fact that I really felt my insurance should and would, if it was approached correctly, approve my surgeries.

Now let’s talk about my “extenuating” circumstances. I had an incident as a teenager that likely wrote me a fast check to obesity without my even realizing it. After failing physical education my freshman year of High School I had to attend summer school to make up for it. Summer school PE consisted of a 2 hr class that lasted I dunno 8 weeks or something and consisted of pretty much the students walking around the football field over and over again for 2 hours. The Teacher watched, and did whatever he did on his clipboard, planning football plays for the next season, who knows. After about three days of this 2 hr class I started to get a rash on my arms. Next it started to appear between my chest and my neck. Once it started to appear on my hands my Mother took me to the doctor who informed us that I was photosensitive, or “allergic to the sun,” as he put it. This got me out of PE for the rest of my High School career and opened up another elective slot for me which is why I got to do so much academic participation. It’s also probably why I never got a chance to learn that I might enjoy exercise or that I loved to run. I wonder sometimes what would have happened, changed or been different in my life if someone had helped me find my love for running when I was fourteen instead of thirty-four.

This sun allergy never really bothered me too much through my teens and twenties. Being as big as I was it wasn’t like I spent a lot of time in the sun or outdoors at all for that matter. When it did start to rear its head again was when Jason and I were first married back in 2003. We were spending a lot of time outdoors letter boxing when I had lost a bunch of weight and even as I started gaining it back, we still stayed pretty active we just did shorter walks and easier hikes. When we got back from a two-week camping trip in the summer of 2005 and my face looked like something off that movie “Mask” with Cheer and the boy with the distorted head, I knew it was time to start bugging my doctor. After a lot of tests, a Dermatologist finally diagnosed me with Discoid Lupus – in case you aren’t familiar with what that is I have provided a link. Some doctors believe that it was the skin disorder that Michael Jackson had that began altering the pigment of his skin and turned him to plastic surgery to begin with. It is also the same skin condition that the Singer Seal has been diagnosed with. For me personally, it manifested itself in this red bumpy risen rash in any area where the sun touched my skin, where I sweat a lot, or where my skin touched. This became a very problematic issue for me in areas like where my excess skin caused folds. I started to get sores anywhere that my skin touched; under my armpits, under my breasts, between my thighs, on my mons, on my labia. Even at times on the backs of my thighs and on my stomach itself.

Now at this point, I started laying the ground work for where I knew I was going to be going. Every doctor that I saw, I talked to them about my weight loss and my skin issues and the health problems that it caused me. As an example, I had to see my OBGYN as part of my pre-op medical requirements for my gastric bypass. When I saw her, I let her know what I was about to do. Every time I saw her after that, whether it was for a bump or an annual exam, I mentioned the excess skin issues to her and discussed how they affected my female hygiene. Same with my primary care doctor, anytime I went to see him about anything, I had him document whatever bumps, sores, rashes or other skin irritation I had going on at the time. I talked to my dermatologist, my PCP, my OBGYN, and of course my Bariatric Surgeon. I made sure I took pictures, lots of pictures, of every bump, rash, infection, anything that could be blamed on the excess skin on my body, I documented the hell out of it.

I had talked to my insurance company upfront and they had told me something that I feel was key in our success. Even my surgeons office was shocked at what my insurance company approved. But from the very beginning they kept stressing this to me: My insurance covered nothing pre op and nothing post op, they covered only the surgery at a $25,000 lifetime maximum. They were very strict about this. Very strict. They did not cover anything pre-op for my Gastric Bypass. They also do not cover my post op follow-up after the initial 90 days after surgery. So my one year follow-up and any lab work that has to be done, are all on my dime. The thing I found interesting though, and where I started thinking outside the box was when my insurance said they covered any “Complications” and that the $25,000 lifetime maximum did not apply to covered complications. I asked my insurance company “Wouldn’t excess skin be a complication of Gastric Bypass surgery? I mean I wouldn’t have excess skin if I had not lost all this weight and I’d not have lost all the weight if i had not had the Gastric Bypass.” They didn’t confirm that for me, in fact their answer was sort of vague, but it was enough for me to know that I needed to find a Surgeon who was willing to look at my skin removal surgeries as a medical necessity and as a complication of Gastric Bypass surgery if I wanted to see my insurance cover it.

I shared my suspicious with my Surgeon from go about how my medical insurance needed to be billed and how i thought it needed to be looked at as a complication of surgery that also caused complications with my pre-existing discoid lupus. I’d love to get my hands on the paperwork that went from my surgeons office to the insurance company and be able to say “This is what worked.” All I know for sure is that all three of my surgeries have been covered by my insurance company. I never had to submit any photos or anything like that, I got my approval based on what my surgeon submitted on the first surgery.

The insurance denied us the first time we submitted to them on the second surgery. When I spoke to them, they said that they did not feel there was enough documentation regarding the skin issues that we were treating and asked for more documentation that the surgery was medically necessary. After a discussion with my surgeon where we both agreed that the implants I was planning to get were not medically necessary, but the rest was, she wrote a letter to the insurance company that stipulated as much and within a few days we had the approval and were ready to go. My final surgery, the thigh surgery I just did last week, was also approved on the first try. I never had to submit an appeal or anything like that through the entire process.

Financially, my insurance covered the first surgery at 80%, it covered the second and third surgery at 100% because I had reached my out-of-pocket max for the year. Now people ask me what the plastic surgery has cost me total. That’s really hard for me to answer because there are other expenses than just what you pay doctors. There is also the issue of time off. And I had to take quite a bit of time off after the first surgery. What I can say, is that so far, I took out a loan for $22,500 to fund my first surgery, before we got the insurance approval. So far, we have used the funds from that loan to pay our portion of the first surgery and to cover the time that I’ve taken off for all three surgeries. To date, so far we have used $17,500 of the loan funds. Considering the fact that I fully expected that loan to only cover the first surgery and that we have been able to use to pay our portion and cover my time off from all three surgeries this year, I consider that quite a feat.

I want everyone to understand that I am NOT in any way saying that your insurance will approve your plastic surgeries if you approach things the way I did. I’m 100% confident that it was a combination of my Discoid Lupus causing even more medical issues with my excess skin and it being considered a complication of Gastric Bypass surgery that convinced my insurance to approve these surgeries. That is a very unique combination and one I highly doubt most can mimic. I think the lesson here is that you need to think outside the box and communicate very well with those involved. I think it is very important to have several doctors willing to advocate for you; When I spoke to the nurse that worked on pre-approvals at my insurance company after they denied the second surgery and she told me that they wanted more documentation on the skin issues that the surgery would treat and more clarification that it was medically necessary, I asked her. “Would you like a letter from my PCP. OBGYN, Dermatologist, or Bariatric Surgeon?” I heard her chuckle a little before she said “Any of those would be fine, a clarification letter from the Plastic Surgeon would work as well.”

I believe that insurance companies should be covering these reconstructive surgeries. The emotional and physical benefits from me having these surgeries must out weigh the costs in the long-term. I’d love to see someone do some research in this area to help start to push insurance companies in that direction. What I do know is that my insurance company covered all of my surgeries thus far, and if I only ever had done what they covered, I would be ok with that for sure. I consider myself very lucky to have gotten what I got done with the help of my insurance. I’m also very passionate about trying to make sure that others are as fortunate as I was. So if there is any advice that I can give you based on my own journey, it is to explore every option and communicate really well with your insurance company and Surgeon. Push your surgeon to at least try to submit based on medical necessity and to appeal at least once as well.

That’s my experience with my insurance company and getting my surgeries approved. If you have any questions please feel free to use the comments section and I will try to answer them the best I can!

I have skin overlapping my stomach, its sometimes smell like rotting flesh, I am considering talking to my doctor about having the panniculetomy to get rid of the excess skin. I did not have weight loss surgery but I did have a hysterctomy quit a few years ago. I am hoping that my insurance will cover it. I have bbcs and medicare. I hope you can help me convience the insurance company to pay for this surgery. The smell is awaful,it sweats and itches something terrible. Thank you so much for your input.